Every finding on record at Centra Health Inc.

An unannounced Home Health Agency recertification survey was conducted on March 31, 2025, through April 04, 2025, by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency March 31, 2025, through April 04, 2025, by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency was found to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. Deficiencies were identified and cited in this report.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, interview and agency procedure, it was determined the agency failed to ensure accurate and complete medication lists were documented in one (1) of (17) clinical records reviewed in the survey sample (Clinical records for Patient #: 1). The findings: 1. The clinical record for Patient #1 was reviewed for the period of February 06, 2025 to April 06, 2025. The plan of care indicated Skilled Nurse visits once a week for one (1) week, two (2) times for three (3) weeks and once a week for two (2) weeks. In addition, the plan of care indicated Physical Therapy once a week for one (1) week, tow (2) times for seven weeks and once a week for one (1) week. A Skilled Nursing and Physical Therapy visit of March 18, 2025 both indicated the patient went to the emergency department on March 14, 2025 and was treated for a urinary traction infection with a new antibiotic to be picked up by the patient's child this day. The clinical record indicated two (2) more Physical Therapy visits on March 21, 2025 and March 24, 2025 with no indication of a new antibiotic documented in the notes or medication list. On March 27, 2025, a Skilled Nurse visit did not indicate a new antibiotic in the notes or medication list. On April 02, 2025 at 4:05 PM, Staff Member #10 was called and revealed writing the patient's son was to pick up the medication but the next visits of March 21, 2025 and March 24, 2025, were assumed nursing would get the medication update. On April 02, 2025 at 4:15 PM, Staff Member #11 was called and revealed by the time nursing visit was made, the patient had finished the antibiotic and the bottle was thrown away. The agency’s medication list failed to contain the new antibiotic medication. On April 04, 2025 the agency's process for the medication profile was reviewed as follows: "Home Health Medication Profile-MM.01.01.01" with a revision date of August 07 2023. The process indicated during subsequent home visits, the medication profile will be updated and used as a care planning and teaching guide to ensure that the patient and family/caregiver understand the medication regimen throughout care. This includes but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach purpose of medication, dosages, routes administration times, side effects and contraindications. C. Using the medication profile as a communication tool for other clinicians/professionals involved in the care. The agency failed to update the patient's medication profile as noted above.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to ensure the physician was notified of the patient's condition that may suggest outcomes are not being met or changes are needed in the plan of care. Specifically, the physician was not notified about out of range vital sign parameters for one ()1 of (17) clinical records reviewed in the survey sample (Clinical record for Patient #: 12). The findings: 1. The clinical record for Patient #12 was reviewed for the certification period of January 03, 2025 to March 03, 2025. The patient's plan of care contained a primary diagnosis of Hypertensive heart and chronic kidney disease with heart failure and orders as follows: Perform vital signs each visit, notify Provider if systolic blood pressure less than 80 and if a cardiac patient, notify Provider of systolic blood pressure less than 90. The clinical record on January 16, 2025 indicated a Skilled Nursing report of patient dizzy and blood pressure dropped from 120/72 to 88/58. In addition, Physical Therapy made a visit on the same day of January 16, 2025 and indicated the patient's blood pressure of 88/50 while standing and feeling light headed. The visits on January 16, 2025 revealed a systolic blood pressure less than 90 and a primary diagnosis as a cardiac patient. On April 03, 2025 at 4 PM, it was revealed Staff Member #12 was on PTO (paid time off) and was unavailable for interview. On April 03, 2025 at 4:13 PM, Staff Member #13 revealed the doctor was aware of the patient's orthostatic issues but can't remember all the incidents. On April 04, 2025 the agency's process for physician communication was reviewed as follows: "Home Health Physician Communication- PC.02.02.01g" with a revision date of August 07 2023. The process indicated to maintain ongoing communication with the physician, as appropriate , to ensure safe and appropriate care for the patient. 1. Contact to the patient's Signatory/Primary Physician will occur. The clinician involved in the activity is ultimately responsible for ensuring the communication but communication may enlist assistance and coordination from other team member. B. When there are changes in the patient's condition or adverse event. 2. All conferences or attempts to communicate with Signatory/Primary Physician will be documented in the clinical record. The clinical record failed to notify the physician of the above out of range parameters.

An unannounced Home Health Agency recertification survey was conducted on March 1-3, 2021 by three (3) Medical Facilities Inspectors from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

Three (3) Medical Facilities Inspector (MFI) from the Office of Licensure and Certification, Virginia Department of Health conducted a Recertification survey at the above noted agency March 1-3, 2021. The survey occurred both onsite and remotely due to the COVID-19 Public Health Emergency. This is a revised report for a correction in Tag 442 only. The agency reported 1665 unduplicated admissions in the last 12 months. The facility was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined the agency failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Medicare patients in advance of terminating care for one (1) of two (2) patients whose closed/discharge clinical record was reviewed in the survey sample for which a NOMNC was applicable. (Clinical Record #4). In addition, the agency failed to provide a Home Health Change of Care Notice (HHCCN) to Medicare patients in advance of reducing/discontinuing services for two (2) of two (2) patients whose clinical records were reviewed in the survey sample for which a HHCCN was applicable (Clinical Records #4 and #16) Findings: Seventeen (17) clinical records were reviewed in the agency on 3/2 to 3/3/2021 with read only access with the following findings: 1. The clinical record of Patient #4 a Medicare beneficiary contained skilled nursing discharge from the agency on 2/12/2020. The plan of care contained orders of skilled nursing once a week for five weeks. During the clinical record review on 3/2/2021 at 1:00 PM the MFI (Medical Facilities Inspector) asked the Clinical Manager (staff member #10) why skilled nursing services discontinued on 2/12/2020 prior to the five weeks as ordered by the physician. Staff member #10 was unable to provide documentation of why skilled nurse services were discontinued. The clinical record failed to contain evidence the agency provided the patient an advanced notice/Home Health Change of Care Notice (HHCCN) prior to terminating skilled nursing visits. In addition, the patient was discharged from the agency on 2/13/2020 by therapy services. On 3/3/2021 Registered Nurse Performance Improvement (staff member #9) provided the MFI with the patient's NOMNC that was signed on the day of discharge. The clinical record failed to contain evidence the agency provided the patient a written notice of discharge/Medicare Notice of Non-Coverage (NOMNC) 48 hours prior to discharge from the agency. 2. The clinical record of Patient #16 a Medicare beneficiary contained skilled nursing discharge from the agency on 2/26/2021. The plan of care contained orders of skilled nursing twice a week for four weeks then once a week for four weeks beginning 2/21/2021. During the clinical record review on 3/3/2021 at 9:00 AM the MFI (Medical Facilities Inspector) asked the Registered Nurse Performance Improvement (staff member #9) why skilled nursing discontinued services on 2/26/2021 prior to the four weeks as ordered by the physician. Staff member #10 was unable to provide documentation of why skilled nurse services were discontinued. The clinical record failed to contain evidence the agency provided the patient an advanced notice/Home Health Change of Care Notice (HHCCN) prior to terminating nursing services. The patient continued to receive services from the agency. The lack of providing patients a written notice in advance of reducing or terminating on-going care was acknowledged by the Administrator (staff member #1), Registered Nurse Performance Improvement (staff member #9) and the Clinical Manager (staff member #10) during the clinical record reviews and again during the exit conference conducted in the agency on 3/3/2021 at 2:15 PM.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the agency staff failed to follow the plan of care for two (2) of 17 patients whose clinical records were reviewed in the survey sample (Clinical records #6 and #10). Findings: Seventeen (17) clinical records were reviewed in the agency on 3/2 to 3/3/2021 with read only access with the following findings: 1. The clinical record for patient #6 was reviewed for the recertification period of 1/17/2021 to 3/17/2021. The plan of care contained orders to cleanse left buttock cavity with normal saline, pack with gauze daily. The clinical record contained documentation by skilled nursing on the dates of 2/7/2021 and 2/22/2021 that tegaderm (transparent dressing) was used to the wound. On 3/2/2021 at 2:30 PM the MFI (Medical Facilities Inspector) asked the Physical Therapist Clinical Manager (staff member #11) to provide an order for the tegaderm used in the above noted notes. Staff member #11 verified there was no physician order for the tegaderm. In addition, a home visit was conducted on 3/3/2021 at 1:00 PM and the MFI observed the skilled nurse applying tegaderm to the buttock site. The clinical record failed to contain documentation that the patient's physician was notified of the wound care services not being provided in accordance with the patient's plan of care. 2. The clinical record for patient #10 was reviewed for the recertification period of 2/4/2021 to 4/4/2021. The plan of care contained a diagnosis of systolic congestive heart failure and physician orders were to assess patient's weight record and trend every visit and notify cardiology for a weight gain or loss of 3 lbs in one to two days or 5 lbs in a week. The clinical record contained documentation of one (1) weight recorded out of six (6) skilled nursing visits. The clinical record failed to contain documentation of the patient's weight being recorded every visit as ordered in accordance with the patient's plan of care. The lack of documentation regarding services being provided according to the above noted plans of care was reviewed and acknowledged by the Administrator (staff member #1), Registered Nurse Performance Improvement (staff member #9) and the Clinical Manager (staff member #10) during the clinical record reviews and again during the exit conference conducted in the agency on 3/3/2021 at 2:15 PM.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview it was determined the agency failed to ensure the patient's individualized plan of care included evidence the patient participated in goal setting and/or agreed with goals identified by the Home Health Agency for 17 of 17 patients whose clinical records were reviewed in the survey sample (Clinical records: #1-#17) Findings: Seventeen (17) clinical records were reviewed in the agency 3/2 to 3/3/2021 with read only access with the following findings: The plan of care for the patients listed below failed to contain documentation or evidence the patient/caregiver participated in goal setting. 1. The clinical record for patient #1 was reviewed for the certification period of 7/29/2020 to 29/26/2020. 2. The clinical record for patient #2 was reviewed for the certification period of 6/21/2020 to 8/19/2020. 3. The clinical record for patient #3 was reviewed for the certification period of 6/17/2020 to 8/15/2020. 4. The clinical record for patient #4 was reviewed for the certification period of 2/5/2020 to 4/4/2020. 5. The clinical record for patient #5 was reviewed for the certification period of 6/8/2020 to 8/6/2020. 6. The clinical record for patient #6 was reviewed for the certification period of 1/21/2021 to 3/17/2021. 7. The clinical record for patient #7 was reviewed for the certification period of 2/13/2021 to 4/13/2021. 8. The clinical record for patient #8 was reviewed for the certification period of 2/17/2021 to 4/17/2021. 9. The clinical record for patient #9 was reviewed for the certification period of 2/5/2021 to 4/5/2021. 10. The clinical record for patient #10 was reviewed for the certification period of 2/4/2021 to 4/4/2021. 11. The clinical record for patient #11 was reviewed for the certification period of 2/12/2021 to 4/12/2021. 12. The clinical record for patient #12 was reviewed for the certification period of 2/16/2021 to 4/16/2021. 13. The clinical record for patient #13 was reviewed for the certification period of 2/17/2021 to 4/17/2021. 14. The clinical record for patient #14 was reviewed for the certification period of 1/18/2021 to 3/18/2021. 15. The clinical record for patient #15 was reviewed for the recertification period of 1/24/2021 to 3/24/2021. 16. The clinical record for patient #16 was reviewed for the certification period of 1/25/2021 to 3/25/2021. 17. The clinical record for patient #17 was reviewed for the certification period of 2/5/2021 to 4/5/2021. On 3/3/2021 at 10:30 AM the MFI (Medical Facilities Inspector) asked the Administrator (staff member #1) to show the patient/caregiver stated goals on the plans of care. The Administrator was unable to provide the MFI with any patient stated goals for the above clinical records and stated, I will check but I am pretty sure we don't have that. On 3/3/2021 at 1:15 PM the MFI asked the Administrator again to show the patient/caregiver stated goals on the plans of care. The Administrator stated, no but the goals are in agreement with the patient's goals. The above noted findings regarding the lack of the required content of the plan of care was acknowledged by the Administrator (staff member #1), Registered Nurse Performance Improvement (staff member #9) and the Clinical Manager (staff member #10) during the clinical record reviews and again during the exit conference conducted in the agency on 3/3/2021 at 2:15 PM.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on staff observation, staff interview and policy and procedure review, it was determined the agency failed to follow accepted standards of practice related to infection control and prevention; and failed to mitigate the risk of COVID-19 transmission. Specifically, agency staff failed to implement an adequate screening process for visitors to the agency. Findings: The MFIs (Medical Facilities Inspectors) conducted activities in conjunction with the survey on-site at the agency on 3/1-3/2021. Upon entry to the agency on the above dates, no screening activity was conducted by the agency. According to the Centers for Disease Control and Prevention (CDC), a healthcare facility's screening procedure should include screening for the presence of lab-confirmed COVID-19 results within the previous 10 days, the presence of symptoms of COVID-19 or respiratory illness, and exposure to COVID-19 in the previous 14 days (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html). The MFIs were not screened for these criteria at any point during on-site survey activities resulting in increased risk for the transmission of and failure to mitigate the risk of COVID-19. The MFI requested the agency's policy and procedure for the screening process for visitors to the agency on 3/3/2021 at approximately 1:00 PM from the Administrator (staff member #1) during an interview. The Administrator stated, "That's my fault, I should have screened you all." The Administrator provided the MFI (Medical Facilities Inspector) with a written policy and procedure prior to the exit conference on 3/3/2021 at approximately 1:30 PM. The policy as requested was an email from Corporate Communications dated 8/13/2020 and a procedure log titled "COVID Screening Log". The policy read in part as follows: "Allowed visitors must adhere to the following guidelines; must be 18 or older, will only be allowed if they do not have COVID-19 symptoms (fever, cough, shortness of breath), will be screened each time they enter and will be asked a series of questions and have their temperature checked, must wear a mask while in any building throughout the duration of their visit", The above-noted findings was acknowledged by the Administrator (staff member #1), Registered Nurse Performance Improvement (staff member #9) and the Clinical Manager (staff member #10) during the clinical record reviews and again during the exit conference conducted in the agency on 3/3/2021 at 2:15 PM.